Custom surgical guides help improve placement and surgical success. Dr. Kristian Buedts, MD, a foot and ankle surgeon at ZNA Middleheim in Antwerp, Belgium recently shared how he uses weight bearing CT scans to create his own surgical guides, and then how he 3D prints those guides at his hospital.
Dr. Buedts highlighted the challenges associated with arthrosis in younger patients, noting that osteo-arthritis typically develops in younger patients as a post-traumatic symptom. More than half the time, the condition presents as asymmetrical wear of the tibio-talar joint (Witteveen 2013), and realignment surgery is often considered to avoid the implications of ankle replacement and joint fusion in younger patients (Krahenbuhl 2017).
These surgeries have been made easier by the accurate 3D representations made possible with weight bearing CT scans, providing professionals like Dr. Buedts with a more consistent pre-operative planning process that included the following steps:
Computer simulation software aids in generation of 3D models
Displacement is calculated by comparing the affected bone to the normal side through superimposition
Virtual osteotomies are conducted
Commercial software helps translate these simulations into custom-made guides
These guides are 3D printed to assist with the actual surgery
In one case, a patient with ankle instability in the ankle joint as a result of ligamentous laxity and a complex cavo-varus deformity with congruent varus deformity in the ankle joint, among other problems, underwent a corrective dome osteotomy.
While cases such as the patient’s are often hard to reproduce and are difficult to operate on, Dr. Buedts and his team utilized weight bearing CT imaging and the 3D printing of pre-operative guides that were used during the procedure to achieve an extremely positive outcome.
To learn more about the possibilities of weight bearing CT imaging, visit curvebeam.com/contact/.
David J. Soomekh, DPM, is a Diplomate of the American Board of Foot and Ankle Surgery and a Fellow of the American College of Foot and Ankle Surgeons.
In this CurveBeam-sponsored FOOTInnovate webinar, Dr. Soomekh delivers a presentation about how exactly weight bearing CT technology has been integrated into his practice.
Click here to watch the FOOTInnovate webinar. A FOOTInnovate account is required to access.
How Dr. Soomekh Leverages the pedCAT
To begin, let’s dive into how Dr. Soomekh uses the CurveBeam pedCAT system in his practice.
“In a lot of cases, I will go straight to a WBCT scan and not do an X-Ray because I know I am looking for subtleties and I don’t want to give the patient a double dose, ” Dr. Soomekh said. “In some cases you might say I have sort of replaced the plain film machine.”
Dr. Soomekh said that the pedCAT is instrumental in his ability to:
diagnose fractures that are difficult to appreciate on plain film due to bone overlap;
detect stress fractures;
appreciate joint relationships in dislocations more easily;
and get an accurate 3D view of joint changes and subchondral lesions associated with arthritis.
In addition, the pedCAT assists Dr. Soomekh with pre-operative planning and an in early detection of osteomyelitis.
Dr. David Soomekh, DPM, shares patients’ pedCAT scans with them via a tablet. He said the datasets wirelessly upload to the viewer in less than 10 minutes.”
“I [view images on] a mobile device. … It’s wireless, and the image still comes up in about six to eight minutes after it’s processed,” Dr. Soomekh said. “I’ll bring it into the room and show the patient the views and the pathology.”
pedCAT Reimbursements and Authorization
Though the rates presented by Dr. Soomekh are specific to Southern California, they provide valuable insight into the operational benefits of a pedCAT system.
For Medicare, Dr. Soomekh said his reimbursement rate is $130 for a scan. With PPO insurance, the rate can range from $180 to $280, and as high as $350. Dr. Soomekh’s cash-pay rate is $200.
While Medicare doesn’t require authorization, Dr. Soomekh’s practice has implemented some best practices for securing authorization for PPO insurance.
His staff will make a pre-authorization call while the patient is in-office, and billing is held until authorization is received. Occasionally, a peer-to-peer call is required. The patient signs a consent form he or she will be responsible for the cost of the CT if it is not covered by insurance.
“In most cases, I don’t wait until I get the authorization before I go ahead and take the scan,” Dr. Soomekh said. “Some patients ask me to wait until they get the authorization, and we’ll do that. … Otherwise, the staff will be doing an authorization call while we’re doing the scan. If we get authorization right then, we’ll let the patient know.”
Results of Weight Bearing CT in Action
Though a thorough watching of Dr. Soomekh’s webinar will reveal many cases in which weight bearing CT is beneficial, let’s take a look at how the pedCAT helps Dr. Soomekh assess Hallux Valgus.
The system helps Dr. Soomekh in pre-operative planning as he assesses the degree of frontal plate rotation of the first metatarsal and its association with the sesamoids. He can also appreciate the degree of transverse plane angulation at the first metatarsal cuneiform joint, among other benefits.
The image below, for example, provided Dr. Soomekh with a look at the internal rotation of the first metatarsal in a younger patient.
The image below shows the result of corrective surgery for the same patient.
“The sesamoids are underneath, now, in the appropriate position, and the angulation is closed,” Dr. Soomekh said.
pedCAT Benefits
To conclude the webinar, Dr. Soomekh outlined the major benefits of adopting the use of a pedCAT machine at his practice.
These include:
Excellent image quality
Instant results
Immediate and focused treatment for the patient
Patients benefit from “one-stop shop” experience
Increased practice revenue
Images can be sent to radiologist for an official report
UPDATE: The Standing CT Conference has been re-scheduled to Thursday, June 11, 2020. Please contact kirsty.collins@standingct.com.
On March 19, CurveBeam will again proudly serve as the primary sponsor for “Bipedalism: Defining Humanity and Foot & Ankle Surgery,” the National Standing CT Conference.
The event, which provides a one-day course aimed at surgeons, podiatrists, specialist physiotherapists and radiologists interested in the latest weight bearing imaging technology for the foot and ankle, is set to take place in Manchester, England’s City of Manchester Stadium, also known as the Etihad Stadium.
The conference is organized by Standing CT Company, which provides weight bearing CT services via mobile imaging centers to hospitals and orthopedic practices in the United Kingdom and Europe. Standing CT Company exclusively utilizes CurveBeam’s weight bearing CT systems.
The conference will feature a variety of speakers and courses for attendees.
Course organizers include Stephen P. Bendall, MBBS, FRCS, FRSC (Orth), an orthopedic foot and ankle surgeon at Princess Royal Hospital in Haywards Heath, Sajid Butt, MB BS, FCPS, FCPR, a radiologist at Royal National Orthopedic Hospitals in London and Stanmore, Andrew Goldberg, MD, and Matthew Solan, BSc, MB, BS, FRCS (Tr & Orth), Medical Director, Chair of MAB and consultant orthopedic surgeon.
Other faculty include CurveBeam President & CEO Arun Singh, Matthew Welck, MBChB. BSc (hons). MSc. FRCS (Orth), Nicholas Cullen, MBBS, BSc(Hons), FRCS, FRCS(Tr&Orth), Lee Parker, BM MRCS FRCS (Tr. & Orth.) Paul O’Donnell, MBBS, MRCP, FRCR, and Francois Lintz, MD .
Question-and-answer sessions will follow each of the four main discussions.
To book your place at this critical conference, call 0800-047-1010 and provide your contact details or email Kirsty.Collins@standingct.com.
The Florida Podiatric Medical Association will hold the Science & Management Symposium (SAM) in Orlando January 15 – 19. The conference agenda includes a lecture on weight bearing CT imaging presented by Dr. Albert Armstrong, DPM, Professor of Radiology at Barry University School of Podiatric Medicine in Miami Shores, Fl.
Won’t be at the meeting? Click here to read the recap of a similar presentation Dr. Armstrong recently delivered on FOOTInnovate.com.
Albert Armstrong, DPM, MS, BSRS, Professor of Radiology and Medical Director of Advanced Imaging at the Barry University School of Podiatric Medicine, is an important voice in the field of podiatry. He recently delivered a FOOTinnovate webinar titled, “Podiatric Radiology: Weight Bearing CT Imaging as an Essential Tool for Diagnosis.”
The Barry University Foot & Ankle Institute is comprised of three hospital-based podiatry clinics in greater Miami. Barry University podiatry students spend a portion of their third year rotating through these clinics. Barry University acquired a pedCAT system for both clinical and research applications in 2018.
In the webinar, Dr. Armstrong focused on how the CurveBeam pedCAT system improves diagnosis and workflow in clinic.
Click here to watch the FOOTInnovate webinar. A FOOTInnovate account is required.
pedCAT’s Efficiency
Dr. Armstrong explained a pedCAT study takes about the same amount of time and produces about the same amount of radiation as three traditional radiographs of the foot.
“The 3D, weight-bearing CT machine that we have is the pedCAT. … It’s small, compact, and it fits in our X-ray room,” Dr. Armstrong said. “It’s fast and easy, and we get instant results.” And patients often comment on the state-of-the-art technology.
pedCAT datasets can be displayed as Multiplanar Reformats (MPR), providing coronal, sagittal and transverse slices of the anatomy.
pedCAT users can also manually get “slices in virtually any plane,” Dr. Armstrong said.
Dr. Armstrong reviewed several cases from clinic in the webinar. Three of those cases are summarized below.
Case 1
Dr. Armstrong presented a case of a 52-year-old female who had undergone a bunionectomy three decades prior. She presented in clinic with pain in the left foot great toe. The pain was preventing the patient from walking, running and wearing heels.
Traditional X-Ray imaging didn’t provide an adequate look at the patient’s foot due to superimposition of the sesamoids and metatarsals.However, scrolling through the coronal plane of a weight bearing CT exam revealed a large osteophyte plantar of the first metatarsal head that was fused to the tibial sesamoid.
While traditional imagine didn’t provide a clear diagnosis, a coronal view created from the 3D volume revealed a large osteophyte and other factors that were hidden by the superimposition of the sesamoids and metatarsals in the X-Ray exam.
The more complete diagnosis, Dr. Armstrong said, led to a much better surgery plan for the patient.
The pedCAT and 3D volume imaging allows for detailed looks on several layers, as doctors can essentially “peel off,” as Dr. Armstrong puts it, layers ranging from shoes worn during weight-bearing scans to skin and soft tissue, etc.
Case 2
Another case, Dr. Armstrong said, highlights how critical weight-bearing imaging can be.
A 37-year-old male came to the Barry University Foot & Ankle Institute after a work injury was still painful two months later. The patient had fallen at his construction job. He went to the emergency room, where an X-Ray exam was read as negative, and he was diagnosed with an ankle sprain. The treatment prescribed was an ace wrap and a brace.
Two months later, the patient came to the Barry University Foot & Ankle Institute.
A sagittal slice of the weight bearing CT scan showed an intra-articular calcaneal fracture to the subtalar joint, as well as patchy osteoporosis throughout the foot.
The fracture had been completely missed on the initial X-Ray. Patchy osteoporosis can be a sign of complex regional pain syndrome, and is typically radiographically indistinguishable as well.
Case 3
A 70-year-old male with a history of osteoarthritis and Type 2 Diabetes had synthetic cartilage implanted into his 1st MPJ joint 9 weeks prior. The patient had severe pain when standing and walking and had to walk on the lateral edge of his foot to compensate. Plain X-Rays came back negative.
With weight-bearing imaging, the coronal MPR images highlighted first metatarsal head was everted to such a degree that the patient was bearing weight on the tibial sesamoid when standing. That was causing his pain.
Without weight-bearing CT imaging, the rotation of the first metatarsal head in this patient’s foot would not have been revealed.
In summary, Dr. Armstrong said that pedCAT provides fast and efficient weight-bearing CT imaging, highlights the value of 3D volume and MPR images, and helps translate critical weight-bearing images into improved results for patients.
